Overthinking It

Elbowed Out

There are few things more frustrating to the uninformed observer (a label I wouldn’t hesitate to apply to myself in this instance) than the DL dance that often precedes a pitcher’s disappearance into ligament-replacement limbo. We’ve all endured that feeling of agonized uncertainty as a player upon whom our chosen team’s playoff hopes rest hangs suspended over the 60-day abyss by a fraying flexor tendon or a lacerated ligament; of course, any anxiety we feel must be little more than a microcosm of the emotional suffering (to say nothing of the physical discomfort) experienced by the ailing athlete himself.

The narrative can unfold in any number of ways. Maybe the protagonist hears the proverbial “pop” and walks off the mound, clutching his arm in pain as a hush descends upon the assembled onlookers. In other cases, he experiences some soreness on his throw day or while warming in the bullpen and doesn’t answer the bell. Grim faces appear in post-game interviews; quite likely our hero has suffered from arm trouble before, and worries all the more by virtue of his familiarity with his foe.

A few days pass, and the results of an MRI seem to reveal no damage, or suggest only a partial tear of the all-important ulnar collateral ligament (UCL). A medical team prescribes a program of rest and rehabilitation. We follow along from afar as the convalescent’s life becomes a blur of long-toss sessions, simulated games, and, with a little luck, a rehab assignment. In some cases, a pitcher will even return to the major-league roster, either willfully ignoring or temporarily not experiencing a recurrence of his symptoms. With each successive hurdle cleared, we allow our belief that all will be well to take deeper root, until one dark day it happens—our man in uniform suffers a dreaded “setback.” A twinge or two is all it takes to prompt some exploratory surgery, after which it’s announced that the damage was worse than believed—the ligament was torn all the time, and we can kiss those hoped-for innings goodbye.

The eventual verdict is all the worse for the waiting, and as we progress through the stages of grief, our denial turns to anger. Why tease us with the prospect of an imminent return when the damage was already done? After all, if surgery and a lengthy rehabilitation process must be faced in order to obtain sweet activation from the DL, all involved in the process, however peripherally, would like to see the clock started sooner, rather than later. So what’s the holdup?

The reasons to delay a decision to operate range from to the cold calculus of a rational operator to the compassionate consideration of a fellow human being. Until surgery is determined to be absolutely necessary, the pitcher’s employers quite logically wish to explore any and all non-surgical options, which if successful, would maximize the value of their investment. Moreover, no team or doctor wants to write off 12-18 months of a career that’s already finite in length, quite possibly consigning the player’s life's work to the scrap heap in the process (though the risk inherent in going under the knife has decreased over time). The increasingly routine 90-minute procedure that’s come to be known colloquially as “Tommy John” surgery sentences its subject (with the exception of a few cases) to at least a year of painful rehab, a decline in future earning potential, and the frustrating feeling of standing on the sidelines while his teammates fight on without him. So, it’s only natural to make every effort to avoid calling for the scalpel.

I won’t presume to speculate about the degree to which some element of denial or stubborn refusal to confront the facts enters into the picture. Naturally, both the player and the team involved have every incentive to avoid sending the man with the golden arm (no, not that one) under the knife, so there may not be any blame to assign here. That said, depending on the timing of the injury, there’s a real cost associated with unnecessary dallying before entering the OR. Last week, my bearded buddy Tommy Bennettwroteabout the boon to a team’s playoff chances that a returning hurler equipped with a brand-new ligament can be. Naturally, the earlier the return, the greater the boon can be. Erasing the period of delay preceding an inevitable surgery effectively deducts an equivalent stretch from the other end of the operation, allowing the player to maximize his time with an able appendage.

Some pitchers’ dates with doctors in surgical scrubs are preceded by a series of warning signs. I’m not talking about changes in stuff or on-field results (though those may very well exist), but short DL stints and “day-to-day” afflictions hailing from particular regions of the arm. If a pitcher’s elbow acts up without any extraordinary circumstances to explain the pain, it could be something of a fait accompli that the complaining part will give him trouble again in the absence of a fundamental change. As Corey Dawkins asked in The Hardball Times Baseball Annual 2010, “How many times have you heard about a pitcher (usually) complaining about forearm cramping, tightness or inflammation, then coming back to pitch? Then, either later that season or the following season, after it's originally been reported that the pitcher will be shut down for a few weeks to reduce inflammation, he ends up on the surgeon's table.” Clearly, throwing baseballs at speeds exceeding 90 mph isn’t something that the human body evolved to do regularly, and if a pitcher’s elbow breaks down in part from repeated use, it seems like folly to forecast a permanent recovery, absent affixing an RMA to his elbow and overnighting it to Birminghamor overseeing a mechanical change that places less strain on the weak point in the kinetic chain.

As Dawkins wrote elsewhere, “The UCL does not completely heal on its own ever. Without surgery, the area is only stabilized by two methods. First, the elbow can be strengthened up to the point where the muscles take up the slack for the lack of ligament stability. The other method is that scar tissue is built up and the muscles are also strengthened. Regardless neither of these actually heal the tissue of the ligament, they merely control the symptom of instability.” According to BP's injury expert, Will Carroll, doctors usually recommend surgery for a tear of any degree over 25 percent, though some will go as high as a third. Few pitchers experience a rupture (complete tear) of the ligament, and the determination of treatment is complicated by the fact that MRI results can be difficult to interpret, even by a skilled radiologist. In addition, the pitcher's personally picked doctor and the doctor retained by the team may not always agreeon the proper approach.

Though it may have been rhetorical, I wanted to make some effort to answer Dawkins' question. Diving into baseball injury data is apt to make one feel a bit like Alice on the other side of the looking glass. Reliable sources are few and far between, and even the most complete demand a considerable amount of online research to ascertain particulars. Carroll and BP data maven Bil Burke handed me the keys to their injury database, which houses records of DL stints from 2005-09. With the aid of their information, along with a fair amount of supplementary Googling, I identified 64 pitchers who underwent Tommy John surgery in that timeframe, though I wouldn’t stake my life or my reputation on that figure being the official tally.

As far as I can tell, approximately 55 percent of the pitchers who were eventually forced to go shopping at Ligaments “R” Us served at least one separate tour on the DL for an elbow-related issue in the year preceding their surgery (often during the same season). The maladies cited ran the gamut from “soreness” to “inflammation” to “tendonitis” to “bone spurs” to “neuritis,” but in all of these cases, a more serious problem lurked below the surface, whether misdiagnosed, intentionally obscured, or not yet fully deteriorated (since a weakness at one point can cause an injury cascade).

I wouldn't take those results as gospel, and without a complete record of injury complaints that weren't deemed worthy of a DL stint, we're missing an important piece of the puzzle, but it does seem that the majority of those who eventually elect to have TJ surgery cost both themselves and their teams time and money by not acting immediately to fix what ailed them (which isn't to say that their decision-making was necessarily at fault, in light of what they knew and when they knew it). Of course, while many of them may have cost themselves by foregoing surgery initially, many others benefited from their decisions not to go under the knife and made it back to the majors with a minimum of time lost. Further research and more exhaustive data might shed more light on whether pitchers with elbow afflictions have been treated optimally.

Let's take a look at a few examples. Jesse Litsch pitched his last game of 2009 on April 13, but didn't undergo Tommy John surgery until two months later. After the decision to operate was made, Jays manager Cito Gastonremarked, “[The elbow] just kept bothering him. He went back to Florida, he visited [Dr. James] Andrews twice ... you add up the months and it looks like he won't be back for Opening Day (2010), so that's not good news.” As Gaston feared, Litsch didn't make his return until the following June. Two months without Litsch is no great loss to a team ticketed for fourth place, but with another pitcher in another place, the impact of an absence of equivalent length can be measured in the millions.

Pat Neshek is another pitcher on my list who stands out for being slow to the operating table. In May, 2008, Neshek was diagnosed with a partial UCL tear, and rest and rehab were prescribed. Six months later, on the verge of completing his rehab, Neshek experienced discomfort in the same elbow, and an MRI revealed more extensive damage, which caused something of a stir in medhead circles. As a result of the delay, Neshek missed not only the rest of 2008, but all of 2009, as well.

Chris Capuano experienced elbow soreness in mid-March of '09, received a diagnosis of a torn UCL, saw Andrews for a second opinion, and still decided to rest for a month before undergoing surgery, which he could no longer avoid by mid-May. Capuano was already a veteran of a prior TJ surgery. Perhaps his reluctance to succumb to the inevitable for a second time was an understandable byproduct of his suffering the first time around. A host of other pitchers followed similar trajectories, spiraling ever closer to a long-term DL stint while time ticked away.

I shouldn't neglect some of the rosier outcomes of the non-surgical route. Take Ervin Santana, for instance. After being placed on the DL with an elbow strain to start the 2009 season, he went the rest-and-rehab route, and appeared ticketed for surgery. However, he’s managed to avoid an operation thus far, giving the Angels over 250 innings since his successful comeback (though the quality of those innings hasn’t returned to 2008 levels).

In most cases, you wouldn't be able to see the damage without a microscope, but each pitch thrown off a major-league mound takes a toll on the arm that released it. A number of pitchers have already set off upon the long and winding road that leads to the 60-day DL this season. Promising young lefty Brett Anderson has been on and off (mostly on) the DL with elbow problems since April. No sooner had the ink dried on Anderson’s four-year contract extension than the 22-year-old was forced to leave a start against the Indians with tightness in his left elbow. Though the rookie said he initially expected to make his next start, he was placed on the DL with a forearm strain and “elbow irritation.” An MRI revealed a muscle strain near his left flexor tendon, condemning him to 4-6 weeks on the shelf. Long tosses led to bullpen sessions, which turned into a minor-league rehab assignment. The latter went so swimmingly that Anderson returned to a major-league mound, shutting down The Tigers for 5 2/3 innings on May 29. Two innings into his subsequent start, though, he was forced to exit with elbow tightness. Quoth Anderson: “It’s kind of like a reoccurring of what happened last time.”

Another MRI revealed nothing of concern, aside from inflammation, but Anderson went back on the DL regardless. After a period devoid of activity, the pitcher followed a similar rehab progression; after making two minor-league starts, he’s scheduled to take the mound on Friday against the White Sox. Should we call the A’s insane for doing the same thing and expecting different results? Or should we commend them for going to great lengths to avoid opening up Anderson’s arm? I don’t know, and only time will tell whether his wounded wing responds to their course of treatment. Either way, they’ll get another shot at approaching the problem, now that Ben Sheets has succumbed to an elbow ailment of his own.

As Dawkins noted, “The ligament itself never heals itself to the point where it was before and therefore is basically a ticking time bomb.” Until we discover how to prevent ligament damage in the first place—should that day ever come—we should continue to look into whether we're pursuing the optimal strategy for defusing the explosive elbow.

Could there be organizational bias in the handling of Elbow problems? Take the Twins for instance, not only was there a seemingly unnecesary delay in the Neshek case, but also with Lirano and to some extent Nathan. Looking back it appears Joe Mays and Grant Balfour may have gone through the same delayed approach earlier in the decade.

Are there other organizations that pray for things to be duckies and bunnies after rest and rehab? Oakland perhaps?

I wouldn't be surprised if certain organizations exhibit patterns of treatment for these types of injuries, but I haven't looked into whether that's the case.

Anyway, even if certain teams do tend to delay surgeries, I don't think we can dismiss their approaches as wishful thinking. We're not privy to nearly enough information for us to state definitively that someone's doing something wrong.